Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852550 (X3) Date Survey Completed 10/29/2019
Name of Provider or Supplier Dublin Kidney Institute Street Address, City, State 207 Industrial Blvd Ste 2, Dublin, GA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0582 H-IDT OVERSEES HOME TRAINING
CFR(s): 494.100(a)

The interdisciplinary team must oversee training of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis (as defined in ยง494.10) and when the home dialysis caregiver or home dialysis modality changes.


This STANDARD is not met as evidenced by:
Based on a review of records and staff interview, it was determined that the facility failed to show documented evidence that infection control audits were completed by the facility for all Patient Care Staff (RN AA, RN BB, and LPN AA) who administered home hemodialyis (HHD) treatments at Skilled Nursing Facility (SNF), and who were under the supervision and oversight of this facility, after a patient's (P) (P#1's) Hepatitis C Seroconversion was discovered. Hepatitis C or Hep C, is a contagious liver disease caused by the hepatitis C virus (HCV), and can be transmitted via exposure to an infected person's blood/body fluids. Seroconversion is a change from seronegative to a seropositive condition. P#1 was also admitted to a local hospital on 9/12/19 due to shock and an altered mental status of unknown etiology, with sepsis (a life threatening condition that arises when the body's response to infection causes injury to its own tissues or organs.) as one of the possible causes. This deficient practice resulted in an immediate jeopardy (IJ) with harm to one patient (P#1) and a potential harm to the health and safety of the other two patients (P#2 and P#3), who were under the care of this facility and who dialyzed at the SNF. The Facility Administrator was informed of the IJ finding on 10/29/19 at 10:05 a.m. The immediate jeopardy was abated during the survey on 10/29/19 at 4:30 p.m., when the facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy. Findings include: During a review of facility records, the following was revealed: - There were three patients (P#1, P#2, and P#3) who were receiving HHD treatments at the SNF, who were under the care of this facility. - P#1 was admitted to the facility on 11/2018. A Hep C Antibody (Ab) Screen, (a test that looks for hepatitis C antibodies in the bloodstream. A reactive or positive antibody test means a person have been infected with the HCV), was collected from P#1 on 11/29/18, and the result was non-reactive or negative. Another Hep C Ab Screen was collected on 1/2/19, and the result was non-reactive. However, the Hep C Ab Screen lab result of P#1 that was collected on 7/2/19 and resulted on 7/4/19, was reactive (positive) for Hep C. And the subsequent Hep C Ab lab collected on 9/5/19 was also reactive. - P#2 and P#3 were both HCV positive upon admission. - A review of P#1's hospitalization record showed that he was admitted to the hospital on 9/12/19 due to shock and an altered mental status of unknown etiology. Sepsis was one of the possibilities and P#1 was treated with IV antibiotics. He expired on 9/13/19. A review of the facility records showed that the facility administered infection control in-service and re-training of staff on 7/12/19, 8/5/19, and 9/13/19, but there were no records that showed that the facility conducted unannounced observations, and audits of RN AA, RN BB, and LPN AA regarding infection control techniques before, during, and after administering home hemodialysis treatments to P#1, P#2, and P#3, to verify if their re-training or in-service was effective and infection control techniques were consistently followed. A review of the Department of Health's investigation on 8/6/19, revealed that handwashing/hand hygiene was one of the infection control breaches that was identified. There were no facility records regarding observations and audits about the staffs' hand hygiene practices and glove use and changes. During an interview with the Facility Administrator (FA) on 10/28/19 at approximately 3:00 p.m., the FA stated that she observed them but these observations were not recorded. She further stated that RN AA also observed RN BB and LPN AA, but there were no records of RN AA's audits and observations either. The IJ was abated during the survey on 10/29/19 at 4:30 p.m. when the FA conducted the following: - An unannounced infection control audit was conducted by the FA using the Center for Disease Control and Prevention (CDC) Infection Control Checklist. - The findings of the audits were discussed with RN AA, RN BB, and LPN AA individually. - The FA conducted a re-training/inservice on Infection Control Manual that included hand hygiene, PPE, and cross contamination.